You are welcome to make an appointment to discuss treatment of your skin cancer at our clinic in Cleveland, Brisbane Bayside.
A good treatment for small sun spots but relatively expensive.
What is Picato gel?
Picato® gel (Ingenol Mebutate) is the newest of the topical treatments for Solar Keratosis. Its main attraction is that the course of treatment is just 2 or 3 days. Side effects often last 1-2 weeks although this is a shorter time than with other topicals. As with any new medication, it takes times for its role to become established as experience increases and new studies are released.
How effective is Picato gel?
The high quality randomised controlled trial upon which the licensing of Picato was published¹ in 2012. As with most new medications, the trials compared the medication with a placebo rather than comparing the medication with established treatments.
The clearance rate at 8 weeks is quoted in the trials as:
- Face & Scalp: Complete Clearance in 42% of participants, Partial Clearance in 64%, and an average reduction of lesions 83%
- Rest of Body: Complete Clearance in 34% of participants, Partial Clearance in 49%, and an average reduction in lesions 75%
The recurrence of Solar Keratosis at 12 months is 54% for the face/scalp and 56% for the rest of the body.
So there’s no simple answer – this is a changing field, and different thought-leaders will give different opinions.
As with any new medication, it takes times for its role to become established as experience increases and new studies are released, but Picato gel looks promising.
How is Picato gel used?
The gel must be kept refrigerated. The gel comes in two different strengths with the lower strength preparation being appropriate for use on the face and scalp.
- 0.05% Picato Gel for the trunk and limbs. Applied once per day for 2 days.
- 0.015% Picato Gel for the face and scalp. Applied once per day for 3 days.
Your Skin Cancer doctor will advise your which area to treat. It should not be used near the eye and not applied to healing wounds. The maximum treatment area is 5cm by 5cm.
The gel is applied to dry skin and left on for at least 6 hours. Do not use it in the 2 hours leading up to bedtime. Most people will therefore find it most convenient to apply it in the morning. Keep the skin dry for at least 15 minutes after application. You should wash your hands after use.
Be particularly careful when applying Picato gel anywhere near the eye because there have been reports of severe eye injuries. Be careful that the Picato doesn’t get transferred to the eye by sweating or washing / showering.
What are the side effects of Picato gel?
The side effects may be:
- Itching, Pain – each in around 8%, Irritation in around 3%
- Redness – very common, to be expected
- Flaking / Scaling or Crusting – to be expected
- Blisters or Pustules – common
- Erosion or ulceration: Least common
Localised skin reactions²
- Usually occur within 1 day of starting treatment
- Peak in intensity up to 1 week after finishing treatment
- Usually resolve within 2 weeks of starting treatment on the face or scalp, and within 4 weeks of starting treatment elsewhere
Rarely non-local symptoms such as headache may occur.
There have been rare reports of severe allergic reaction (anaphylaxis)³.
A Fact of life for many Australians!
What is Efudix?
How does Efudix work?
Sunlight damages DNA and makes many genes in skin cells “behave” abnormally. For example, p53 is a “good” gene that suppresses abnormal growth of cells. UVB stops this gene from working properly so that abnormal cells start to appear, manifesting as solar keratosis (sun spots).
Efudix works by blocking the production of both DNA and RNA, predominantly in the epidermal skin cells (Keratinocytes). Most new production of DNA occurs in pre-cancerous or cancerous cells and so efudix, in a sense, targets the abnormal cells. This has important practical implications. Efudix makes sunspots inflamed. However, efudix also works on the abnormal skin cells that you can’t see. When you treat a whole area of the body with efudix then red patches will appear both on the sunspots and on some areas of skin that previously appeared to look normal. This is called “field treatment” because a whole “field” of skin is being treated. This is in contrast to only argeting visible areas with, for example, cryotherapy.
Which area should be treated?
The first thing to decide is which area of the body to treat. Efudix can be applied just to individual lesions, or to whole areas (a “field”). Field treatment is generally better when there is thought to be significant sun damaged that may not yet be visible. Let’s say there are 4 sunspots (solar keratosis) on the backs of both forearms. In this situation, it is sensible to take the opportunity to treat the whole field.
The maximum surface area that can be treated at one time is 500 cm² (23 cm x 23cm). This corresponds to the following areas:
- A third of the diameter of both forearms (the sun-exposed areas) + the backs of the hands.
- A wider area of both forearms (half the diameter) – without the backs of the hands.
- or most of the face and forehead.
- or both shins.
As you can see, it’s not possible to treat all the areas typically affected by sunspots at the same time. You might be asked to treat the face & forehead first, followed by the forearms later. Treating the face and forehead can be split up into two separate treatment periods if the area affected is greater than 500 cm² or for your comfort (treating both together might be too intense an experience).
What are the side effects of efudix?
The treated areas of sun-damaged skin become red, crusty & sore after 2 to 4 weeks. These side effects indicate that the cream is working! The list of side effects are: Itching, redness, burning sensation, severe peeling, intense swelling or inflammation, blistering, ulceration, irritation, pain, hives and rash.
Allergy to efudix can sometimes develop. An allergic reaction to efudix makes the skin inflamed in all areas that have been treated. Efudix will normally make only the sun damaged skin red – there are “gaps” of normal looking skin in-between red inflamed areas.
It is possible (but unusual) to get scarring if the inflammation causes excessive inflammation.
How long is Efudix used for?
For Sun Spots, Efudix for solar keratosis is used twice daily for 2 weeks on the face, and twice daily for 4 weeks on the limbs. There are different schedules and your skin cancer doctor will advise you accordingly. Whilst side effects are expected, you may be asked to stop treatment if you develop symptoms such as widespread crusting, a dusky red skin colour or increased itching.
For IEC, Efudix is generally used twice per day for around 8 weeks or as advised by your doctor.
How is Efudix Cream used?
A pea-sized amount of cream is enough to cover a cheek or chin or forehead. Four pea-sized amounts of cream covers the whole face and forehead. The maximum area treated at one time should not exceed 23 x 23cm.
Avoid contact within 1cm of eyes or mouth, and avoid use under the arms or in the groin. It’s important to minimise sunlight and use sun protection.
Wash your hands well after application. You may apply moisturizer 20 minutes after application of the efudix.
Do I need an appointment during the treatment period?
The treatment is often an intense experience. It is generally a good idea to make an appointment with the doctor 10 to 14 days after starting treatment. A steroid cream may be recommended to help settle down the side effects. It is rare that efudix treatment needs to be stopped.
It’s also also possible you may be asked to be reviewed in 6 weeks to look at any lesions that have not responded.
Efudix may be an intense experience!
How long Does Efudix last for?
This is a tricky one! Different studies give different results. A large review study found that over 60% of people required re-treatment with efudix after 1 year.⁴ It has been clearly shown that sun protection reduces the development of further sunspots. So it’s really important to protect your skin, and this will help reduce the frequency of re-treatments. It is then possible to go 5 years between treatments.⁵
Diclofenac gel has mild to moderate anti sun-spot properties.
What is Solaraze Gel?
Solaraze® Gel is 3% Diclofenac Gel and licensed for the treatment of Solar Keratosis.
Diclofenac is commonly used in weaker strengths (e.g. 1%) as a topical anti inflammatory for aches and pains (eg. Voltarol gel). Solaraze is inthe same class of medication as Ibuprofen / Neurofen.
How is Solaraze Gel used, and how long is it used for?
Solaraze is applied to a whole field of solar keratosis twice daily for around 3 months.
What are the side effects of Solaraze?
Side effects are common but usually mild:
A small amount is absorbed through the skin (as with other anti-inflammatory creams and gels). There are cautions therefore with its use. For example, it should not be used with an active stomach ulcer.
How effective is Solaraze Gel?
Solaraze Gel is generally considered to be the least effective of the main topical treatments for solar keratosis – but also has the fewest side effects.
Imiquimod cream is commonly used for superficial BCC.
What is Imiquimod (Aldara®)?
Imiquimod cream is available both as branded Aldara® or as a generic Imiquimod cream. The cream is used in the treatment of some types of skin cancer & genital warts. The cream works by stimulating the immune system to attack the skin cancer cells. It is commonly used in the skin cancer clinic and available under medicare for superficial BCC where surgery is not appropriate.
How is Imiquimod cream used?
The cream is applied at night to the affected area that also includes application of the cream to a 1cm margin of healthy looking skin around the lesion. This ensures that any abnormal skin cells outside of the visible edge of the lesion are also treated. The cream is then washed off in the morning.
Wash your hands after applying the cream. You may apply moisturiser around 20-30 minutes after application.
The treatment is not approved in Australia for use immediately next to the eyes, mouth, nose or ears. However, many skin cancer doctors will be comfortable using the treatment in these areas – particularly the nose or ears. Particular care should be taken when used near the eyes.
How often should I used Imiquimod, and for how long?
There are a range of different treatment schedules & it’s important to follow the specific advice given to you. A starting-point is the following:
- For superficial Basal Cell Carcinoma: 5 nights per week (monday to friday) for 6 weeks.
- For Solar Keratosis: 3 nights per week for 4 weeks – this may be repeated after a month’s gap (rest) if required.
- For Intraepithelial Carcinoma: A variety of off-license treatment schedules are used – similar schedule to superficial Basal Cell Carcinoma.
It’s not possible to be prescriptive about duration of treatment because some people get a more severe local reaction whilst others get only minor side effects. For more severe reactions, there may be a treatment gap prescribed so that the same number of days treatment is spread over a longer period.
What are the side effects of Imiquimod cream?
Local Skin Reactions are to be expected and indicate that the cream is working:
- Itching, Burning and/or discomfort are very common.
- Redness – to be expected
- Erosions (common),
- Ulceration, Oozing, Weeping, Scabbing/crusting – these indicate a more severe reaction
There is great variation in how sensitive skin is to these side effects. Severe reactions will mean that the treatment should be reduced in intensity – it may be stopped or may be reduced in frequency. Studies suggest that “breaks” in treatment (provided the number of days application is the same) do not reduce the effectiveness.
There may be reduced Pigmentation (or less commonly increased pigmentation) following treatment (sometimes permanent).
Systemic Flu-like symptoms may also occur:
- Headache, muscle aches, Backache
- Nausea, Diarrhoea
These systemic effects are caused by activation of the immune system which is how the Imiquimod works. There is no need to stop the treatment when the symptoms are mild and can be controlled with paracetamol.
How effective is Imiquimod for Skin Cancer Treatment?
As a rough guide only (studies vary):
- Solar Keratosis: Bear in mind that the treatment is approved in Australia for treating up to 5 cm² at a time & Solar Keratosis often affects a much wider area of skin than this. Treatment may be recommended off-license for a wider area however. Five randomised trials6 7 8 9 10 indicate that up to 72% of patients achieve a 75% clearance. Another way of looking at it is that complete clearance is achieved in 45% to 57%.
- Superficial Basal Cell Carcinoma: 82% for superficial BCCs11 though Imiquimod t should only be used for this type of BCC. A biopsy is usually required prior to treatment. Generally not recommended on the head & face (less effective).
- Intraepithelial Carcinoma: Imiquimod is 73% effective.12